CCApplication2018

Curiosity Club Summer 2018
July 9 - July 27

* Indicates required field

Child's First Name *

Child's Last Name *

Age *

Birthday *

School *

Grade (prior to summer) *

Additional Child's First Name *

Age *

Birthday *

School *

Grade (prior to the summer) *

Primary Contact Name *

First

Last

Relationship *

Primary Phone Number *

Primary Email *

Primary Address *

Line 1

Line 2

City

State

Zip Code

Country

Secondary Contact Name *

First

Last

Relarionship *

Secondary Phone Number *

Secondary Email *

Secondary Address (if different from above) *

Line 1

Line 2

City

State

Zip Code

Country

Please share anything that would be helpful to know about your child(ren) so they have the best experience possible? (ie: favorite things, personality traits, medical concerns, allergies, social/emotional concerns, special interests, etc.....) *

How did you find out about Curiosity Club? (If a friend, please share who, etc.) *

Liability Waiver *

Yes, I understand by registering my child(ren) I will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which might occur as a result of participation.

Permission Waiver *

Yes, I give permission for my child(ren) to be photographed / videotaped. These photos and videos will be used for documentation and promotional purposes. They may appear in our print materials, on our website, or social media sites such as facebook

Payment may be made online, or through Chase QuickPay anita@neurokitchen.org, or checks may be sent to "NeuroKitchen Arts Collective" and mailed to 3358 N. Monticello 1W, Chicago, IL 60618

If you have any questions please contact anita@neurokitchen.org

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Curiosity Club Summer 2018​July 9 - July 27

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Curiosity Club Summer 2018
July 9 - July 27